INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15-17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings include:
The facility's fire drill log for the time frame of October 2012 to September 2013 was reviewed on October 15, 2013. The facility failed to conduct any fire drills during sleeping hours from October 2012 to September 2013.
The facility director confirmed the findings.
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Plan of Correction
The Safety Officer has revised the schedule for fire drills to include a drill during sleeping hours at least once every six months. The first sleeping hours drill will occur in November 2013. |